Compositions and Methods for Suppressing Endometrial Proliferation

ABSTRACT

The subject matter of the instant invention is pertinent to the field of hormone therapy. More specifically, the subject matter of the instant invention concerns methods of treating estrogen-dependent conditions such as endometrial hyperplasia and endometrial cancer in a female undergoing estrogen and/or selective estrogen receptor modulator (SERM) therapy. The instant invention is also relevant to the suppression of endometrial proliferation. The instant invention is also relevant to the treatment of pain associated with endometriosis. The compositions for practicing the methods, comprising progesterone antagonists are also disclosed. Embodiments of the instant invention also disclose methods for identifying new selective progesterone receptor modulators for practicing disclosed methods of treatment.

CROSS-REFERENCE TO RELATED APPLICATIONS

The application is a continuation of U.S. application Ser. No.12/446,567, filed Apr. 27, 2010 which is the U.S. national stage ofInternational Patent Application No. PCT/US07/082,432 filed Oct. 24,2007, and which claims the benefit of U.S. Provisional PatentApplication No. 60/862,632, filed Oct. 24, 2006, and U.S. ProvisionalPatent Application No. 60/885,348, filed Jan. 17, 2007, the contents ofeach of which is incorporated herein by reference in its entirety.

FIELD OF THE INVENTION

The present invention relates to compositions and methods for thesuppressing endometrial proliferation. More specifically, the presentinvention relates to compositions comprising one or more progesteroneantagonists for suppressing endometrial proliferation.

BACKGROUND OF THE INVENTION

Estrogens are a group of hormones essential for a variety of physiologicprocesses including the development of the uterus and breasts, themaintenance of bone density, and cardiovascular protection through itspositive effect on lipid profiles. The effects of estrogen are mediatedthrough its binding to estrogen receptors in the nucleus. According tothe classic model, unoccupied estrogen receptor in the nucleus, uponbinding estrogen, acquires the ability to interact with DNA sequenceswithin the promoters of estrogen-responsive genes. The DNA-boundestrogen receptor modulates the transcription of these genes, eitherpositively or negatively.

Estrogen is known to have a hyperproliferative effect on breast anduterine tissue. Administration of unopposed estrogen to menopausalwomen, for example, has been demonstrated to lead to both endometrialhyperplasia and endometrial cancer. In contrast, progesterone potentlycounteracts estrogen-dependent endometrial proliferation and cancerdevelopment. Therefore, to counteract the effects of unopposed estrogen,progestin is commonly prescribed as part of a hormone replacementtherapy (HRT). However, a large clinical study from the Women's HealthInitiative recently determined that the combination of conjugatedestrogen and medroxyprogesterone acetate increased the risk ofdeveloping cardiovascular disease, stroke, pulmonary embolism and breastcancer. Additionally, experimental data in macaques made surgicallymenopausal has shown that a regimen of combined estrogen andprogesterone led to higher levels of breast proliferation andhyperplasia then estrogen alone. Coadministration of progestin has alsobeen associated with break-through bleeding, further limiting itssuitability as an agent for countering the hyperproliferative effects ofestrogen.

Many compounds are known in the art which affect estrogen-dependentactivation of the estrogen receptor. Depending on a variety of factorsthese compounds may be entirely estrogenic, in that they mimic estrogen,entirely antiestrogenic, in that they block the effects of estrogen, orthey may fall somewhere in-between. Compounds which exhibit mixedestrogenic and antiestrogenic properties are termed selective estrogenreceptor modulators (SERMs). SERMs exert their estrogenic orantiestrogenic effects in a tissue-specific manner. The mechanismunderlying this tissue-specificity is not clear, but may involve, interalia, the recruitment of corepressor and coactivator proteins whoserelative expression levels vary among tissue types and tissue-specificexpression of estrogen receptor isoforms α and β. Estrogen receptor α isan activator whereas estrogen receptor β can inhibit estrogen receptor aactivity by forming a heterodimer with it.

The dual activities of SERMs provide several potential advantages towomen. The estrogenic properties of SERMs may be used to treat orprevent diseases caused by estrogen deficiency such as osteporosis,while minimizing some of the undesirable effects of estrogen.Conversely, the antiestrogenic properties of SERMs may be used toprevent or treat diseases such as breast cancer, in which estrogenicactivity is undesirable. Nonetheless, endometrial hyperplasia has beenassociated with SERM therapy, thus limiting its usefulness.

The SERM tamoxifen, for example, has been shown to be antiestrogenic inthe breast where it blocks the proliferative effects of estrogen and hasconsequently found favor as a treatment for certain types of breastcancer. On the other hand, tamoxifen displays estrogenic effects on boneand the uterus and has been associated with an increased incidence ofendometrial hyperplasia and endometrial cancer, limiting it's usefulnessas an antiestrogen.

A preliminary study in primates appeared to indicate that antiprogestinspossess antiproliferative effects on the endometrium. However, there isconcern that long-term treatment with antiprogestins could result inendometrial hyperplasia due to the action of unopposed estrogen. Severalrecent investigations in adult women have revealed a thickening of theendometrium during long-term treatment with high doses ofantiprogestins, presumably a consequence of unopposed estrogen activity,which does not appear to occur with low doses.

There remains a need for a treatment regimen suitable for long-termadministration which opposes the proliferative effects of estrogen whilemaintaining the beneficial effects of estrogen on the body.

SUMMARY OF THE INVENTION

The instant invention provides methods for suppressing endometrialproliferation comprising administering to a patient in need thereof, anamount of a progesterone antagonist effective to suppress proliferationin endometrial tissue. The patient in need thereof may be a female withendometriosis. The progesterone antagonist may be a pure antiprogestinor a selective progesterone receptor modulator (SPRM). In a preferredembodiment, the progesterone antagonist has low affinity forglucocorticoid receptor. In another preferred embodiment, administrationof the progesterone antagonist to a female reduces luteal phaseprogesterone levels in the female. In yet another preferred embodiment,administration of the progesterone antagonist to a female does notsubstantially lower estrogen levels in the female.

In yet another aspect, the instant invention provides methods of usingprogesterone antagonists in estrogen and SERM therapies to prevent anestrogen-dependent condition. More specifically, the instant inventionemploys progesterone antagonists at dosages sufficient to suppressendometrial proliferation in females undergoing treatment regimenscomprising the administration of an estrogen or SERM. For example, thepatient may be a menopausal or post-menopausal female undergoing hormonereplacement therapy. In yet another aspect, the invention providesmethods for preventing the development of endometrial hyperplasia and/orendometrial cancer using progesterone antagonists in estrogen and SERMtherapies. The progesterone antagonist may be an antiprogestin or aselective progesterone receptor modulator (SPRM) so long as theprogesterone antagonist is used in an amount effective to suppressendometrial proliferation.

In yet another aspect, the instant invention provides methods of usingprogesterone antagonists in the treatment of pain associated withendometriosis. The progesterone antagonists may be used for long-termtreatment of pain associated with endometriosis.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is a graph depicting the effect of selective progesteronereceptor modulators on serum cortisol in rats.

FIG. 2 is a graph depicting the dose-dependent effect of CDB-4124 onserum cortisol in rats.

DETAILED DESCRIPTION OF THE INVENTION

The term “effective dosage” means an amount of the composition's activecomponent sufficient to achieve the desired effect which may be, e.g.,suppression of endometrial proliferation or treatment of pain associatedwith endometriosis.

The term “selective progesterone receptor modulators” means compoundsthat affect functions of progesterone receptor in a tissue-specificmanner. The compounds act as progesterone receptor antagonists in sometissues (for example, in the uterus) and as progesterone receptoragonists in other tissues.

The terms “treat” or “treatment” refer to both therapeutic treatment andprophylactic or preventative measures, wherein the object is to preventor slow down (lessen) an undesired physiological change or disorder. Forpurposes of the present invention, beneficial or desired clinicalresults include, but are not limited to, alleviation of symptoms,diminishment of extent of disease, stabilized (i.e., not worsening)state of disease, delay or slowing of disease progression, ameliorationor palliation of the disease state, and remission (whether partial ortotal), whether detectable or undetectable. “Treatment” can also meanprolonging survival as compared to expected survival if not receivingtreatment. Those in need of treatment include those already with thecondition or disorder as well as those prone to have the condition ordisorder or those in which the condition or disorder is to be prevented.

The term “progesterone agonist” means a compound that binds to aprogesterone receptor and mimics the action of the natural hormone.

The term “progesterone antagonist” means a compound that binds to aprogesterone receptor and inhibits the effect of progesterone.

The term “suppress” or “suppresses” or “suppressing” used herein inreference to proliferation of endometrial tissue means that mitoticproliferation of endometrial tissue is suppressed upon administration ofa progesterone antagonist relative to untreated endometrial tissue underidentical conditions and is to be distinguished from cell death via,e.g., apoptosis. The activity of a progesterone antagonist insuppressing endometrial mitotic proliferation may be tested, e.g., in auterine cell line by, e.g., comparing the incorporation ofbromodeoxyuridine (BrdU) in cells treated with a progesterone antagonistto control (untreated) cells.

The term “not substantially reduced” as used herein in reference tohormone levels in a female means that hormone levels are maintainedwithin the normal range during administration of compositions of theinvention. Thus, it is considered that some reduction in a hormone levelmay occur so long as the hormone level is maintained within the normalrange.

The term “not substantially increased” as used herein in reference tohormone levels in a female means that hormone levels are maintainedwithin the normal range during administration of compositions of theinvention. Thus, it is considered that some elevation in a hormone levelmay occur so long the hormone level is maintained within the normalrange.

The present invention relates to the use of progesterone antagonists atdoses effective to suppress endometrial proliferation. The methods arisefrom the unexpected finding that certain progesterone antagonistsexhibit an inverse dose dependent effect on endometrial proliferation,while maintaining estrogen levels within the normal range. Specifically,it has been found that chronic administration of a high dosage of theantiprogestin/SPRM CDB-4124 suppresses endometrial proliferation whilelower doses fail to suppress endometrial proliferation and even tend topromote endometrial proliferation, despite similar levels of estrogenobserved at high and low dosages. This is particularly surprising inview of the inability of the antiprogestin/SPRM RU 486 to suppressendometrial proliferation at a high dosage, demonstrated below, andseveral recent reports that chronic administration of high doses ofantiprogestins promotes endometrial proliferation, presumably due to theeffects of unopposed estrogen. The present invention also demonstratesthat progesterone antagonists are unexpectedly useful in treating painassociated with endometriosis.

The suppression of endometrial proliferation during a treatment regimencomprising the daily administration of an effective amount of aprogesterone antagonist over a six month period, described below,demonstrates the usefulness of such progesterone antagonists wherechronic/long-term administration is desired. In this regard, methods ofthe invention may comprise administering a composition comprising anamount of a progesterone antagonist sufficient for suppressingendometrial proliferation for an administration period of least 1, 2, 3,4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22,23, 24, 25, 26, 27, 28, 29, 30, 31 or more days. The composition mayalso be administered for an administration period of least 1, 2, 3, 4,5, 6, 7, 8, 9, 10, 11, 12 or more months. The composition may also beadministered for an administration period of at least 1, 2, 3, 4, 5, 6,7, 8, 9, 10 or more years. During the administration period, thecomposition may be administered daily or periodically such as everyother day, every other month, and the like. The composition may also beadministered intermittently. For example, the composition may beadministered for an administration period of 1, 2, 3, 4, 5 or moremonths, followed by a period of discontinuance, followed by anadministration period of 1, 2, 3, 4, 5 or more months, and so on.

By “intermittent administration” it is meant a period of administrationof a therapeutically effective dose of progesterone antagonist, followedby a time period of discontinuance, which is then followed by anotheradministration period and so forth.

By “period of discontinuance” or “discontinuance period” it is meant adiscontinuing of the daily, weekly, monthly or therebetweenadministration of progesterone antagonist. The time period ofdiscontinuance may be longer or shorter than the administration periodbut is always longer than the dosing interval during the administrationperiod. For example, where the administration period comprises daily,weekly, or monthly dosing, the discontinuance period is at least 2 days,at least 8 days or at least 32 days, respectively. Thus, thediscontinuance period may be at least about 2, 3, 4, 5, 6, 7, 8, 9, 10,11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28,29, 30, 31, 32 or more days.

In one embodiment, the composition is administered intermittently suchthat the subject undergoes menses during at least one discontinuanceperiod. This approach is expected to avoid the adverse effectsassociated with a thickened or stagnant endometrium that may accompanyextended treatment with progesterone antagonists, such as spotting,breakthrough bleeding, endometrial hyperproliferation or endometrialcancer. At least one, and preferably every discontinuance period is ofsufficient length for the subject to experience menstruation. Morepreferably, the subject experiences menstruation during everydiscontinuance period. In a particularly preferred embodiment, thecomposition is administered daily for an administration period of fourmonths, followed by a discontinuance period during which the subjectexperiences menstruation, followed by another administration period offour months and so on.

Optionally, a gonadtropin-releasing hormone (GnRH) agonist or antagonistmay administered during the discontinuance period to hasten the sheddingand refreshing of the endometrium. Non-limiting examples of GnRHagonists include nafarelin, buserelin, leuprorelin, triptorelin,goserelin, [DLys⁶]GnRH, [DAla⁶]GnRH and the like. Non-limiting examplesof GnRH antagonists include histrelin, abarelix and those found in U.S.Pat. Nos. 4,409,208, 4,547,370, 4,565,804, 4,569,927 and 4,619,914,incorporated herein in by reference in their entirety.

Optionally, a progestin may be administered during the discontinuanceperiod in order to obtain a normal menses in the patient. Administrationof a progestin preferably results in a progesterone profile that mimicsthe natural rise and fall of progesterone levels during menstruation.Such treatment regimens are well known in the art. Administration of aprogestin during the discontinuance period may also provide oppositionto the effects of estrogen in addition to that received byadministration of the progesterone antagonist and therefore may helptreat estrogen-dependent conditions such as thickening of theendometrium. Non-limiting examples of progestins include medrogestone,medroxyprogesterone, megestrol, norethindrone, progesterone,hydroxyprogesterone, acetoxypregnenolone, allylestrenol, cyproterone,desogestrel, dimethisterone, ethisterone, ethynodiol diacetate,gestadene, lynestrenol and the like.

In one embodiment, a female patient with endometriosis is administered acomposition comprising a progesterone antagonist in an amount effectiveto suppress endometrial proliferation. In a related embodiment, acomposition comprising a progesterone antagonist is administered to afemale with endometriosis in an amount effective to treat painassociated with endometriosis. For example, administration of theprogesterone antagonist may reduce pain associated with endometriallesions. Pain is the most prevalent and debilitating symptom ofendometriosis and is the primary indication for both medical andsurgical treatment of the disease. Pain may be manifested asdysmenorrheal, pelvic pain, back pain, abdominal pain, breast pain,dyspareunia and the like. Administration of the progesterone antagonistmay also reduce the size of the endometrial lesions. Current regimensfor the treatment of endometriosis include GnRH agonists which induce astate of pseudomenopause by inhibiting ovarian estrogen secretion andare therefore not useful for long-term administration due to loss inbone density, loss of total body calcium and other osteoporosis-likeside effects. Compositions of the invention may be administeredlong-term with no substantial decrease in estrogen levels.

In another embodiment, the present invention provides methods oftreating an estrogen-dependent condition associated with current hormonetherapies which employ estrogenic compounds such as estrogens or SERMSby co-administering an amount of a progesterone antagonist effective tosuppress endometrial proliferation. Estrogen-dependent conditionsassociated with current estrogen/SERM hormone therapies include, withoutlimitation, endometrial hyperplasia and endometrial cancer. In thisregard, the progesterone antagonist may be administered prior to,during, or subsequent to estrogens or SERMS as part of a combinedhormone therapy regimen.

In yet another embodiment, the present invention provides a method ofhormone replacement comprising administering to a menopausal orpost-menopausal female an effective amount of a progesterone antagonistand an estrogenic compound, wherein the amount of a progesterone agonistis effective to suppress an estrogen-dependent condition. The estrogeniccompound may be an estrogen or a SERM. The estrogenic compound may beadministered prior to, subsequent to, or may be co-administered with,the progesterone antagonist. The estrogen-dependent condition may be,without limitation, endometrial proliferation, endometrialhyperproliferation or endometrial cancer.

In a preferred embodiment of each method of the invention,administration of the progesterone antagonist to a female does notsubstantially reduce estrogen levels in the female. Thus the presentinvention provides an advantage over current therapies for the treatmentof endometriosis which often employ gonadotropin-releasing hormone(GnRH) agonists such as Lupron® (leuprolide acetate).

In another preferred embodiment of each method of the invention,administration of the progesterone antagonist to a female does notsubstantially increase progesterone levels in the female. Morepreferably, administration of the progesterone antagonist to a femalereduces progesterone levels in the female, particularly luteal phaseprogesterone levels.

In yet another preferred embodiment of each method of the invention, theprogesterone antagonist exhibits reduced affinity for the glucocorticoidreceptor. More preferably, the binding affinity of the progesteroneantagonist for the progesterone receptor is at least 1.5 times greaterthan the binding affinity of the progesterone antagonist for theglucocorticoid receptor.

Any known progesterone antagonist with characteristics of the compoundsdescribed above can be used by an artisan practicing the instantinvention. Particularly useful compounds include those disclosed in U.S.Pat. No. 6,900,193, hereby incorporated by reference in its entirety, aswell as those disclosed in U.S. Pat. No. 6,861,415, hereby incorporatedby reference in its entirety, that are 21-substituted 19-norpregnaneswith a general formula:

wherein:X may be, for example alkyl, alkenyl, alkynyl, hydrogen, halo,monoalkylamino or dialkylamino, such as N,N-dimethylamino;R₁ may be, for example O, NOH or NO-methyl;R₂ may be, for example hydrogen or acetyl; andR₃ may be, for example methyloxy, formyloxy, acetoxy, acyloxy, S-alkoxy,acetyltheonyl, glycimate, vinyl ether, acethyloxymethyl, methylcarbonate, halogens, methyl, hydroxy, and ethyloxy.

The examples of 21-substituted 19-norpregnanes include, but are notlimited to, the following 24 compounds disclosed below.

1. CDB-4247 (21-propionyloxy-17α-acetoxy-11β-(4N,N-dimethylaminophenyl)-19-norpregna-4,9-diene-3,20-dione) with thefollowing structural formula:

2. CDB-4361 (21-vinyl ether-17α-acetoxy-11β-(4N,N-dimethylaminophenyl)-19-norpregna-4,9-diene-3,20-dione) with thefollowing structural formula:

3. CDB-4059 (21-acetoxy-17α-acetoxy-11β-(4N,N-dimethylaminophenyl)-19-norpregna-4,9-diene-3,20-dione) with thefollowing structural formula:

4. CDB-4124 (21-methoxy-17α-acetoxy-11β-(4N,N-dimethylaminophenyl)-19-norpregna-4,9-diene-3,20-dione) with thefollowing structural formula:

5. CDB-4031 (21-bromine-17α-acetoxy-11β-(4N,N-dimethylaminophenyl)-19-norpregna-4,9-diene-3,20-dione) with thefollowing structural formula:

6. CDB-3876 (21-chlorine-17α-acetoxy-11β-(4N,N-dimethylaminophenyl)-19-norpregna-4,9-diene-3,20-dione) with thefollowing structural formula:

7. CDB-4058 (21-flourine-17α-acetoxy-11β-(4N,N-dimethylaminophenyl)-19-norpregna-4,9-diene-3,20-dione) with thefollowing structural formula:

8. CDB-4030 (21-methyl-17α-acetoxy-11β-(4N,N-dimethylaminophenyl)-19-norpregna-4,9-diene-3,20-dione) with thefollowing structural formula:

9. CDB-4152 (21-hydroxy-17α-acetoxy-11β-(4N,N-dimethylaminophenyl)-19-norpregna-4,9-diene-3,20-dione) with thefollowing structural formula:

10. CDB-4167 (21-ethyloxy-17α-acetoxy-11β-(4N,N-dimethylaminophenyl)-19-norpregna-4,9-diene-3,20-dione) with thefollowing structural formula:

11. CDB-4101 (21-methoxythio-17α-acetoxy-11β-(4N,N-dimethylaminophenyl)-19-norpregna-4,9-diene-3,20-dione) with thefollowing structural formula:

12. CDB-4110 (21-acetonide-17α-acetoxy-11β-(4N,N-dimethylaminophenyl)-19-norpregna-4,9-diene-3,20-dione) with thefollowing structural formula:

13. CDB-4111 (21-BMD-17α-acetoxy-11β-(4N,N-dimethylaminophenyl)-19-norpregna-4,9-diene-3,20-dione) with thefollowing structural formula:

14. CDB-4125 (21-(Cyp*-hydroxy)-17α-acetoxy-11β-(4N,N-dimethylaminophenyl)-19-norpregna-4,9-diene-3,20-dione) with thefollowing structural formula:

15. CDB-4205 (3-hydroxyamino-21-methoxy-17α-acetoxy-11β-(4N,N-dimethylaminophenyl)-19-norpregna-4,9-diene-3,20-dione) with thefollowing structural formula:

16. CDB-4206 (3-hydroxyamino-21-acetoxy-17α-acetoxy-11β-(4N,N-dimethylaminophenyl)-19-norpregna-4,9-diene-3,20-dione) with thefollowing structural formula:

17. CDB-4226 (3-hydroxyamino-21-ethyloxy-17α-acetoxy-11β-(4N,N-dimethylaminophenyl)-19-norpregna-4,9-diene-3,20-dione) with thefollowing structural formula:

18. CDB-4262 (3-methoxyamino-21-ethyloxy-17α-acetoxy-11β-(4N,N-dimethylaminophenyl)-19-norpregna-4,9-diene-3,20-dione) with thefollowing structural formula:

19. CDB-4223 (21-methylthio-17α-acetoxy-11β-(4N,N-dimethylaminophenyl)-19-norpregna-4,9-diene-3,20-dione) with thefollowing structural formula:

20. CDB-4119 (4-benzoin-21-acetylthio-17α-acetoxy-11β-(4N,N-dimethylaminophenyl)-19-norpregna-4,9-diene-3,20-dione) with thefollowing structural formula:

21. CDB-4239 (4-benzoin-21-methoxy-17α-acetoxy-11β-(4N,N-dimethylaminophenyl)-19-norpregna-4,9-diene-3,20-dione) with thefollowing structural formula:

22. CDB-4306 (21-glycinate-17α-acetoxy-11β-(4N,N-dimethylaminophenyl)-19-norpregna-4,9-diene-3,20-dione) with thefollowing structural formula:

23. CDB-4352 (21-cyanothio-17α-acetoxy-11β-(4N,N-dimethylaminophenyl)-19 norpregna-4,9-diene-3,20-dione) with thefollowing structural formula:

24. CDB-4362 (21-methoxyacetyl-17α-acetoxy-11β-(4N,N-dimethylaminophenyl)-19-norpregna-4,9-diene-3,20-dione) with thefollowing structural formula:

11β-monodemethylated derivatives of the 24 compounds disclosed above(i.e., those in which X is N-methylamino) are also particularly usefulin practicing the instant invention. In this regard, CDB-4453(21-methoxy-17α-acetoxy-11β-(4-N-methylaminophenyl)-19-norpregna-4,9-diene-3,20-dione),a monodemethylated derivative of CDB-4124, has been demonstrated topossess even lower anti-glucocorticoid activity than its parent. Attardiet al., 2002, Mol. Cell. Endocrin. 188:111-123, the contents of whichare incorporated herein by reference.

Although compounds of the general formula above and theirmonodemethylated derivatives are preferred, any progesterone antagonistmay be used in the practice of the present invention for its antagonisteffect on the progesterone receptor. Preferably, the progesteroneantagonist has one or more of the following characteristics: lowantiglucocorticoid activity, minimal estrogenic and anti-estrogenicactivities, and does not substantially elevate progesterone levels.

Antiprogestins which may be useful in the invention include, withoutlimitation, asoprisnil (benzaldehyde,4-[(11β,17β)-17-methoxy-17-(methoxymethyl)-3-oxoestra-4,9-dien-11-yl]-1-(E)-oxim;J867), its metabolite J912(4-[17β-Hydroxy-17α-(methoxymethyl)-3-oxoestra-4,9-dien-11β-yl]benzaldehyd-(1E)-oxim),and other compounds described in DE 43 32 283 and DE 43 32 284; CDB-2914(17α-acetoxy-11β-(4-N,N-dimethylaminophenyl)-19-norpregna-4,9-dien-3,20-dione)and other compounds described in Stratton et al., 2000, Hu. Reprod.15:1092-1099; JNJ-1250132 and other compounds described in Allan et al.,2006, Steroids 71:949-954; 5-Aryl-1,2-dihydrochromeno[3,4-f]quinolinesdescribed in Zhi et al., 1998, J. Med. Chem. 41:291-302;1,4-dihydro-benzo[d][1,3]oxazin-2-ones described in U.S. Pat. Nos.6,509,334, 6,566,358 and 6,713,478 to Zhang et al.;1,3-dihydro-indol-2-ones described in U.S. Pat. No. 6,391,907 to Fensomeet al.; 2,3-dihydro-1H-indoles described in U.S. Pat. No. 6,417,214 toUlrich et al.; benzimidazolones and analogues thereof described in U.S.Pat. No. 6,380,235 to Zhang et al.; 2,1-benzisothiazoline 2,2-dioxidesdescribed in U.S. Pat. No. 6,339,098 to Collins et al.; cyclocarbamatesand cyclo-amides described in U.S. Pat. Nos. 6,306,851 and 6,441,019 toSantilli et al.; cyclic urea and cyclic amide derivatives described inU.S. Pat. No. 6,369,056 to Zhang et al.; and quinazolinone andbenzoxazine derivatives described in U.S. Pat. No. 6,358,948 to Zhang etal.

Other antiprogestins that may be useful in the invention include,without limitation,(6α,11β,17β)-11-(4-dimethylaminophenyl)-6-methyl-4′,5′-dihydrospiro[estra-4,9-diene-17,2′(3′H)-furan]-3-one(ORG-31710) and other compounds described in U.S. Pat. No. 4,871,724;(11β,17α)-11-(4-acetylphenyl)-17,23-epoxy-19,24-dinorchola-4,9,20-trien-3-one(ORG-33628);(7β,11β,17β)-11-(4-dimethylaminophenyl-7-methyl]-4′,5′-dihydrospiro[estra-4,9-diene-17,2′(3′H)-furan]-3-one(ORG-31806) and other compounds described in U.S. Pat. No. 4,921,845;ZK-112993 and other compounds described in Michna et al., 1992, J.Steroid Biochem. Molec. Biol. 41:339-348; ORG-31376; ORG-33245;ORG-31167; ORG-31343; RU-2992; RU-1479; RU-25056; RU-49295; RU-46556;RU-26819; LG1127; LG120753; LG120830; LG1447; LG121046; CGP-19984A;RTI-3021-012; RTI-3021-022; RTI-3021-020; RWJ-25333; ZK-136796;ZK-114043; ZK-230211; ZK-136798; ZK-98229; ZK-98734; and ZK-137316.

Still other antiprogestins that may be useful in the invention include,without limitation, mifepristone(11β-[p-(Dimethylamino)phenyl]-17β-hydroxy-17-(1-propynyl)estra-4,9-dien-3-one;RU 486) and other compounds described in U.S. Pat. Nos. 4,386,085,4,447,424, 4,519,946 and 4,634,695; the phosphorus-containing 17β-sidechain mifepristone analogues described in Jiang et al., 2006, Steroids71:949-954; onapristone(11β-[p-(dimethylamino)phenyl]-17α-hydroxy-17-(3-hydroxypropyl)-13α-estra-4,9-dien-3-one)and other compounds described in U.S. Pat. No. 4,780,461; lilopristone(((Z)-11β-[(4-dimethylamino)phenyl]-17-β-hydroxy-17α-(3-hydroxy-1-propenyl)estra-4,9-dien-3-one)and other compounds described in U.S. Pat. No. 4,609,651; the11(3-substituted 19-norsteroids, such as11β-(4-Methoxyphenyl)-17β-hydroxy-17α-ethynyl-4,9-estradien-3-onedescribed in Belagner et al., 1981, Steroids 37:361-382; the11β-aryl-4-estrenes such as(Z)-11β-[(4-Dimethylamino)phenyl)]-17β-hydroxy-17α-(3-hydroxy-1-propenyl)estr-4-en-3-onedescribed in U.S. Pat. No. 5,728,689; the 11β-aryl-estrene derivativesdescribed in U.S. Pat. Nos. 5,843,933 and 5,843,931; the11-benzaldoxime-estradiene derivatives such as4-[17β-Methoxy-17α-(methoxymethyl)-3-oxoestra-4,9-dien-11β-yl]benzaldehyde-1-(E)-oximedescribed in U.S. Pat. No. 5,693,628; the11-benzaldoxime-17β-methoxy-17α-methoxymethyl-estradiene derivativessuch as4-[17β-Methoxy-17α-(methoxymethyl)-3-oxoestra-4,9-dien-11β-yl]benzaldehyde-1-(E)-[O-(ethylamino)carbonyl]oximedescribed in U.S. Pat. No. 5,576,310; the S-substituted11β-benzadoxime-estra-4,9-diene-carbonic acid thiolesters such as4-[17β-Methoxy-17α-(methoxymethyl)-3-oxoestra-4,9-dien-11β-yl]benzaldehyde-1-(E)-[O-(ethylthio)carbonyl]oxime,described in WO 99/45023; the steroid esters such as(Z)-6′-(4-cyanophenyl)-9,11α-dihydro-17β-hydroxy-17α-[4-(1-oxo-3-methylbutoxy)-1-butenyl]4′H-naphtho[3′,2′,1′;10,9,11]estr-4-en-3-onedescribed in DE 19652408, DE 4434488, DE 4216003, DE 4216004 and WO98/24803; the fluorinated 17α-alkyl chain steroids such as11β-(4-acetylphenyl)-17β-hydroxy-17α-(1,1,2,2,2-pentafluoroethyl)estra-4,9-dien-3-onedescribed in WO 98/34947; the 17-spirofuran-3′-ylidene steroids such as11beta-(4-Acetylphenyl)-19,24-dinor-17,23-epoxy-17alpha-chola-4,9,20-trien-3-onedescribed in U.S. Pat. No. 5,292,878;(Z)-11beta,19-[4-(3-Pyridinyl)-o-phenylene]-17beta-hydroxy-17α-[3-hydroxy-1-propenyl]-4-androsten-3-oneand other compounds described in U.S. Pat. No. 5,439,913; the13-alkyl-11-beta-phenyl gonanes such as11beta-[4-(1-methylethenyephenyl]-17α-hydroxy-17beta-(3-hydroxypropyl)-13α-estra-4,9-dien-3-onedescribed in U.S. Pat. No. 5,446,036; the 11-arylsteroids such as4′,5′-Dihydro-11beta-[4-(dimethylamino)phenyl]-6beta-methylspiro[estra-4,9-dien-17beta,2′(3′H)-furan]-3-onedescribed in U.S. Pat. No. 4,921,845; the 11-beta-aryl-estradienesdescribed in U.S. Pat. Nos. 4,829,060, 4,814,327 and 5,089,488; the11-beta-aryl-4,9 gonadiens and 11-beta-aryl-13-alkyl-4,9-gonadiensdescribed in U.S. Pat. Nos. 5,739,125, 5,407,928 and 5,273,971; the11-beta-aryl-6-alkyl (or alkenyl or alkinyl) steroids described in EP289073; the 10-beta,11-beta-bridged steroids described in U.S. Pat. No.5,093,507; the 11-beta-aryl-14-beta-steroids described in U.S. Pat. No.5,244,886; the 19,11-beta-bridged steroids described in U.S. Pat. Nos.5,095,129, 5,446,178, 5,478,956 and 5,232,915; the 1-arylsulphonyl,arylcarbonyl and 1-arylphosphonyl-3-phenyl-1,4,5,6-tetrahydropyridazinesdescribed in U.S. Pat. No. 5,684,151; the 1-arylsulphonyl, arylcarbonyland arylthiocarbonyl pyridazino derivatives described in U.S. Pat. No.5,753,655; the 1,2-dihydro-[1,2-g]quinoline derivatives and1,2-dihydro-chromeno-[3,4-f]quinoline derivatives described in U.S. Pat.Nos. 5,688,808, 5,693,646, 5,693,647, 5,696,127, 5,696,130 and5,696,133; the oxa-steroids 6 derived from(8S,13S,14R)-7-oxa-estra-4,9-diene-3,17-dione 1 described in Kang etal., 2007, Bioorg. Med. Chem. Lett. 15:907-910; and the 7-oxa-steroids 4described in Kang et al., 2007, Bioorg. Med. Chem. Lett. 17:2531-2534.

In the preferred embodiment, the progesterone antagonist is theantiprogestin/SPRM CDB-4124 (21-methoxy-17α-acetoxy-11β-(4N,N-dimethylaminophenyl)-19-norpregna-4,9-diene-3,20-dione). Example 10demonstrates that administration of CDB-4124 at a high dosage (50mg/day) suppresses endometrial proliferation in adult females, but doesnot suppress endometrial proliferation at lower dosages (25 mg/day and12.5 mg/day).

Progesterone antagonist compositions of the instant invention may begiven to patients undergoing any hormone therapy associated with anincreased risk or incidence of endometrial hyperplasia or endometrialcancer. These treatments may include, but are not limited to, theadministration of estrogens or the administration of SERMs. Progesteroneantagonist compositions of the instant invention can be also given topatients undergoing antiestrogenic treatments because the patients maybenefit from antiproliferative effects that progesterone antagonistcompounds exert in endometrial tissue of the uterus.

SERMs are currently administered to treat various disorders includingbreast cancer, osteoporosis, colon cancer, neurodegenerative diseasessuch as Parkinson and Alzeimer, cardiovascular disease, vaginal atrophyand obesity. However, SERM therapy is associated with endometrialhyperplasia and endometrial cancer. For example, Tamoxifen treatment ofbreast cancer results in about a 20% incidence of hyperplasia withatypia in women with intact uteri. Patients with endometrial specimensdisplaying atypia have a 25% likelihood of progressing to carcinoma.Compounds of the present invention are administered at doses sufficientto oppose the hyperplasia that accompanies treatment with SERMs. Thecompounds of the present invention may be administered in combinationwith SERMs for the treatment of any of the aforementioned disorders.

Estrogens are currently administered as part of hormone replacementtherapy (HRT) to postmenopausal women who no longer produce estrogens.However, estrogen-only therapy is considered unsafe for menopausal womenwith intact uteri because of the accompanying endometrial hyperplasia.Co-administration of progestin is frequently proscribed to oppose thehyperproliferative effects of estrogen; however, the addition ofprogestin has been linked to breast cancer in the WHI studies and canresult in break-through bleeding. The compounds of the present inventionmay be administered in combination with estrogens as part of a hormonereplacement regimen.

The compounds disclosed in the instant invention may act as progesteroneantagonists in the uterus. The compounds of the instant invention may besuitable for the prolonged usage required in menopausal patientsundergoing hormone replacement therapy, as for other indications. Wheresuch usage is considered, the compounds preferably have only lowglucocorticoid receptor binding activity and therefore, the compounds donot substantially interfere with functions of glucocorticoid receptor.Thus, the application of the compounds may have reduced side effects,such as mood swings, fatigue and weight loss, typically found whenantiprogestins with a high affinity for glucocorticoid receptor areused.

In another embodiment the instant invention teaches methods that can beused for identifying compounds that possess selective progesteronereceptor binding activity. These methods include receptor binding and invivo bioassays such as anti-McGinty, anti-Clauberg, glucocorticoid,estrogenic, androgenic, anti-glucocorticoid (AG), anti-estrogen, andanti-androgen activities as well as post-coital and anti-ovulatoryactivities where in the leading compounds of the instant invention areused as a reference.

In another embodiment, the instant invention teaches that the potentialSPRMs can be also analyzed for their effect on transcriptional activityin human cells. When SPRMs disclosed in the instant invention are usedas a reference, this analysis can furnish information about (1) SPRM'sinteraction with receptor, (2) interaction of the activated receptorwith other transcription factors, (3) activation of a transcriptionalcomplex at a progesterone response element (PRE); and ultimately itseffect on gene expression. In these experiments, plasmid expressing thehPR-B can be cotransfected with any reporter known to a person skilledin the relevant art under the PRE-dependent promoter into HeLa, HepG2 orT47D cells. The reporters may include, but are not limited to,luciferase, beta-galactosidase, green fluorescent protein, redfluorescent protein or yellow fluorescent protein. After transfection,the cells are treated with either a test compound or one of thedisclosed in this application SPRMs that serves as a positive control.Following treatment, cells are assayed for reporter expression.

In another embodiment, the instant invention teaches that prospectiveSPRMs can be tested for their ability to oppose dexamethasone-inducedcell death in human lymphocytic cell line CEM-7 and compared to effectsof SPRMs disclosed in the instant specification. In these experiments,dexamethasone can be added at a concentration that results in celldeath. The cells are then treated with either RU486, one of SPRMs of theinstant invention or a test compound at concentrations between 10⁻⁶ and10⁻⁸ M.

Progesterone antagonist compounds that may be used in accordance withthe present invention can be synthesized using synthetic chemistrytechniques known in the art such as those disclosed in U.S. Pat. No.6,861,415. It is to be understood that certain functional groups mayinterfere with other reactants or reagents under the reaction conditionsand therefore may need temporary protection. The use of protectinggroups is described in ‘Protective Groups in Organic Synthesis’, 2^(nd)edition, T. W. Greene & P. G. M. Wutz, Wiley-Interscience (1991).

In one embodiment, compositions of the invention comprise one or moreprogesterone antagonists or pharmaceutically acceptable salts thereof.Depending on the process conditions the salt compound obtained may beeither in neutral or salt form. Salt forms include hydrates and othersolvates and also crystalline polymorphs. Both the free base and thesalts of these end products may be used in accordance with theinvention.

Acid addition salts may in a manner known per se be transformed into thefree base using basic agents such as alkali or by ion exchange. The freebase obtained may also form salts with organic or inorganic acids.

In the preparation of acid addition salts, preferably such acids areused which form suitably pharmaceutically acceptable salts. Examples ofsuch acids are hydrochloric acid, sulfuric acid, phosphoric acid, nitricacid, aliphatic acid, alicyclic carboxylic or sulfonic acids, such asformic acid, acetic acid, propionic acid, succinic acid, glycolic acid,lactic acid, malic acid, tartaric acid, citric acid, ascorbic acid,glucuronic acid, fumaric acid, maleic acid, hydroxymaleic acid, pyruvicacid, aspartic acid, glutamic acid, p-hydroxybenzoic acid, embonic acid,ethanesulfonic acid, hydroxyethanesulfonic acid, phenylacetic acid,mandelic acid, alogenbensenesulfonic acid, toluenesulfonic acid,galactaric acid, galacturonic acid or naphthalenesulfonic acid. Allcrystalline form polymorphs may be used in accordance with theinvention.

Base addition salts may also be used in accordance with the inventionand may be prepared by contacting the free acid form with a sufficientamount of the desired base to produce the salt in the conventionalmanner. The free acid form may be regenerated by contacting the saltform with an acid and isolating the free acid in the conventionalmanner. Pharmaceutically acceptable base addition salts are formed withmetals or amines, such as alkali and alkali earth metals or organicamines. Examples of metals used as cations are sodium, potassium,calcium, magnesium and the like. Examples of suitable amines are aminoacids such as lysine, choline, diethanolamine, ethylenediamine,N-methylglucamine and the like

For the aforementioned purposes, the compounds of the instant inventioncan be administered to a patient via any conventional route where theprogesterone antagonist is active. For instance, a progesteroneantagonist of the instant invention can be administered orally,parenterally, sublingually, transdermally, rectally, transmucosally,topically, via inhalation, via buccal administration, or combinationsthereof. Parenteral administration includes, but is not limited to,intravenous, intraarterial, intraperitoneal, subcutaneous,intramuscular, intrathecal, intraarticular, intracisternal andintraventricular. The administration form can be a tablet, capsule,pill, nasal mist, aerosol, pellet, implant (or other depot) and thelike.

A therapeutically effective amount of the composition required for usein therapy may vary depending on the particular compound employed, themode of administration, the severity of the condition being treated, thelength of time that activity is desired, among other factors, and isultimately determined by the attendant physician. In all cases, aneffective dosage of a particular compound is one that is sufficient tosuppress endometrial proliferation. However, in general, doses employedfor human treatment typically are in the range of about 0.001 mg/kg toabout 500 mg/kg per day, for example about 1 μg/kg to about 1 mg/kg perday or about 1 μg/kg to about 100 μg/kg per day. For most large mammals,the total daily dosage is from about 1 to 100 mg, preferably from about2 to 80 mg. The dosage regimen may be adjusted to provide the optimaltherapeutic response. The desired dose may be conveniently administeredin a single dose, or as multiple doses administered at appropriateintervals, for example as two, three, four or more subdoses per day.

Illustratively, a composition of the invention may be administered to asubject to provide the subject with a progesterone antagonist in anamount of about 1 μg/kg to about 1 mg/kg body weight, for example about1 μg/kg, about 25 μg/kg, about 50 μg/kg, about 75 μg/kg, about 100μg/kg, about 125 μg/kg, about 150 μg/kg, about 175 μg/kg, about 200μg/kg, about 225 μg/kg, about 250 μg/kg, about 275 μg/kg, about 300μg/kg, about 325 μg/kg, about 350 μg/kg, about 375 μg/kg, about 400μg/kg, about 425 μg/kg, about 450 μg/kg, about 475 μg/kg, about 500μg/kg, about 525 μg/kg, about 550 μg/kg, about 575 μg/kg, about 600μg/kg, about 625 μg/kg, about 650 μg/kg, about 675 μg/kg, about 700μg/kg, about 725 μg/kg, about 750 μg/kg, about 775 μg/kg, about 800μg/kg, about 825 μg/kg, about 850 μg/kg, about 875 μg/kg, about 900μg/kg, about 925 μg/kg, about 950 μg/kg, about 975 μg/kg or about 1mg/kg body weight.

The compositions of the instant invention may contain from about 25 toabout 90% of the active ingredient in combination with the carrier, moreusually between about 5% and 60% by weight.

Solid carriers may include starch, lactose, dicalcium phosphate,microcrystalline cellulose, sucrose and kaolin, while liquid carriersmay include sterile water, polyethylene glycols, non-ionic surfactantsand edible oils such as corn, peanut and sesame oils, as are appropriateto the nature of the active ingredient and the particular form ofadministration desired. Flavoring agents, coloring agents, preservingagents, and antioxidants, for example, vitamin E and ascorbic acid, maybe included in preparations as well. Under ordinary conditions ofstorage and use, the preparations may contain a preservative to preventthe growth of microorganisms.

The compositions of the instant invention can be formulated into tabletsin a tablet press by using techniques well-known to an artisan skilledin the relevant field. Optionally, the active ingredients according tothe invention can also be pressed separately into two-layer tablets.According to the instant invention, tablets may include antiestrogens,estrogens or SERMs as one of the active ingredients. Compositions of theinstant invention can also be formulated as an oily solution.

Patients undergoing treatments with the compositions of the instantinvention should be monitored routinely for their serum estrogen andglucocorticoid levels.

The following non-limiting examples are provided to aid in understandingthe teachings of the instant invention.

All patents, patent applications and publications referenced herein arehereby incorporated by reference herein to the fullest extent allowedunder the law.

Example 1 Formulations of the Instant Invention can be Prepared asTablets

To obtain tablets for practicing the instant invention, the followingingredients can be pressed together in a tablet press:

50.0 mg  of CDB-4124 140.5 mg  of lactose 69.5 mg  of corn starch 2.5 mgof poly-N-vinylpyrrolidone 2.0 mg of aerosil 0.5 mg of magnesiumstearate

To obtain two-layer tablets for practicing the instant invention, thefollowing ingredients can be pressed together in a tablet press:

20.0 mg of Tamoxifen 50.0 mg of CDB-4124 105.0 mg  of lactose 40.0 mg ofcorn starch  2.5 mg of poly-N-vinylpyrrolidone 25  2.0 mg of aerosil 0.5 mg of magnesium stearate

To obtain tablets containing antiestrogens for practicing the instantinvention, for example, the following ingredients can be pressedtogether in a tablet press:

10.0 mg of Raloxifene 50.0 mg of CDB-4124 125.0 mg  of lactose 50.0 mgof corn starch  2.5 mg of poly-N-vinylpyrrolidone 25  2.0 mg of aerosil 0.5 mg of magnesium stearate

To obtain oily preparations for practicing the instant invention, forexample the following ingredients can be mixed together and loaded intoampoules:

100.0 mg of CDB-4124 343.4 mg of castor oil 608.6 mg of benzyl benzoate

Example 2 Compounds of the Instant Invention May have Only WeakAntiglucocorticoid Receptor Binding Activity

Certain antiprogestins were tested in receptor-binding assays for theirability to bind rabbit progesterone receptor (rbPR) and glucocorticoidreceptor (rbGR). Briefly, cytosol containing PR or GR were prepared inTEGMD buffer (10 mM Tris, pH 7.2, 1.5 mM EDTA, 0.2 mM sodium molybdate,10% glycerol, 1 mM DTT) from uterus or thymus, respectively, ofestradiol-primed immature rabbits. For PR binding, the cytosol wasincubated with 6 nM 1,2-[³H]progesterone (50.0 Ci/mmole) and competitorswere added at concentrations from 2 to 100 nM. For binding to GR, thecytosol was incubated with 6 nM 6,7-[³H]-dexamethasone (40 Ci/mmol) andtest compounds were added at concentrations from 20 to 100 nM. Afterovernight incubation at 4 C, bound and unbound [³H] steroids wereseparated by addition of dextran-coated charcoal and centrifugation at2100×g for 15 min at 4 C. Supernatants containing the [3H]-steroidreceptor complexes were decanted into vials containing 4 ml Optifluor(Packard Instrument Co.), vortexed, equilibrated in a liquidscintillation counter for 30 minutes and then counted for 2 minutes. TheEC₅₀ (Effective Concentration) for each standard curve and each of thecompound curves was determined by entering the counting data into a fourparameter sigmoidal computer program (RiaSmart® Immunoassay DataReduction Program, Packard Instrument Co., Meriden, Conn.). Relativebinding affinity (RBA) for each compound was calculated using thefollowing equation: EC₅₀ of standard/EC₅₀ of test compound×100. Thestandards for the PR and GR assays were unlabeled progesterone anddexamethasone, respectively. The results of these experiments aresummarized in Table 1, as a ratio of the relative binding affinities ofeach compound for the rbPR and rbGR receptors (rbPR/rbGR). Thisdifferential reflects the relative activity of a compound in a cell ortissue that possesses the two receptors and the requisitetranscriptional cofactors.

Also given in Table 1 are the relative biological activities of the samecompounds in the rabbit uterus by the anti-McGinty and anti-Claubergassays. Compound CDB-2914 (listed at the end of the Table) was used asthe control or reference compound (rabbit Biological Activity=1.00) forthese experiments because results of experiments using CDB-2914 havebeen published before (Hild-Petito et al., 1996; Passaro et al., 1997;Reel et al., 1998; Larner et al., 2000). For the anti-McGinty test,immature female rabbits received a subcutaneous injection of 5 μgestradiol in 10% ethanol/sesame oil daily for 6 consecutive days. On day7, animals underwent sterile abdominal surgery to ligate a 3-4 cmsegment of both uterine horns. The test compound in appropriate solventwas injected intraluminally into the ligated segment of one uterine hornand vehicle alone into the other. A stimulating dose of progesterone(267 μg/day) was administered subcutaneously to each rabbit daily forthe next three days to induce endometrial proliferation. All animalswere sacrificed at day 10 for removal of the uterus where a segmentcentral to the ligatures was removed and fixed in 10% neutral bufferedformalin and submitted for histological processing. Five micron sectionsstained with hematoxylin and cosin were evaluated microscopically forthe degree of endometrial glandular proliferation. The percentinhibition of endometrial proliferation for each rabbit was calculatedand the mean of the group of five animals recorded. For theAnti-Clauberg test, immature female rabbits received a subcutaneousinjection of 5 μg estradiol in 10% ethanol/sesame oil daily for 6consecutive days. On day 7, animals received progesterone bysubcutaneous injection (160 μg/day) and the experimental compound inappropriate vehicle orally or subcutaneously for five consecutive days.One group of rabbits received progesterone only. Twenty-four hours afterthe last dose, all animals were sacrificed for removal of the uteruswhich was cleaned of all fat and connective tissue, weighed to thenearest 0.2 mg and placed in 10% neutral buffered formalin forsubsequent histological processing. Five micron sections stained withhematoxylin and eosin were evaluated microscopically for the degree ofendometrial glandular proliferation. The percent inhibition ofendometrial proliferation at each dose level of the test compound wasderived by comparison with progesterone-stimulated animals alone. Thedata presented in Table 1 (rabbit Biol. Act.) reflects the average ofthe results obtained for each compound by the anti-McGinty andanti-Clauberg assays relative to CDB-2914.

The tested antiprogestins were ranked on the basis of the selectivity ofeach compound for the rabbit PR over the rabbit GR, as listed inTable 1. The antiprogestins were also ranked on the basis of thebiological activity in the rabbit uterus. Data presented in Table 1 showthat the affinity of leading compounds for progesterone receptor was atleast 1.5 times greater than their affinity for glucocorticoid receptor.

The results of these studies also show that the two leading compoundsCDB-4124 and CDB-4059 have strong antiprogestin activity in the rabbituterus in comparison to RU 486 and CDB-2914. Both compounds lackestrogenic, androgenic, anti-estrogenic, and anti-androgenic activities.Both compounds possess minimal anti-glucocorticoid receptor activity, afeature that distinguishes them from RU 486 and CDB-2914 which aremoderately active in glucocorticoid receptor binding. In these assays,CDB-4124 performed slightly better than CDB-4059

TABLE 1 RECEPTOR BINDING AND BIOLOGICAL ACTIVITIES OF SPRMS rabbit Biol.SPRM rbPR/rbGR Act. 4239 14.80 0.60 4241 9.10 0.34 4361 7.20 3.03 43065.90 0.95 4363 5.75 2.53 3875 5.11 1.40 4362 4.74 1.25 4352 4.21 0.574176 3.83 0.20 4243 2.90 0.00 4119 2.60 0.10 4324 2.16 1.10 4247 2.061.70 4205 1.99 1.00 4059 1.89 2.90 4400 1.76 2.29 3247 1.74 0.10 41671.69 1.50 4124 1.58 3.60 4226 1.51 0.54 4206 1.44 0.68 4416 1.33 0.774417 1.31 0.70 4111 1.30 0.36 4125 1.19 1.55 4223 1.17 not given 43981.16 0.99 4058 1.08 0.90 4418 1.03 0.25 4177 1.03 0.00 4030 0.96 0.304374 0.95 2.25 4399 0.93 0.35 4152 0.82 1.40 4110 0.70 0.10 4031 0.690.70 4101 0.61 0.65 4248 0.42 0.00 4227 0.38 0.00 4393 0.35 0.00 43960.18 not given 2914 1.07 1.00

Example 3 Measuring Cortisol

Several different experimental systems support a conclusion that RU 486increases cortisol because RU 486 has strong anti-glucocorticoidproperties in humans and primates.

However, as shown in FIG. 1, rats treated with RU 486 at 10 mg/kg showedno significant difference in the levels of cortisol. In contrast, ratstreated with either CDB-4124 or CDB-4059 at the same dose levels hadsignificantly higher levels of serum cortisol than rats from a controlgroup.

These higher levels were in the range of 3-4 ug/dl (30-40 ng/ml). Theeffects were dose-dependent in that increasing doses of CDB-4124 led toincreased cortisol (FIG. 2).

This difference in effects of RU 486 versus CDB-4124 or CDB-4059 oncortisol levels can be explained by assuming that after 21 days ofchronic dosing, a rat liver was able to metabolize RU 486 better thaneither of the two CDB compounds.

Example 4 Measuring Corticosterone

Corticosterone is the most abundant glucocorticoid in rats. The effectsof the SPRMs on cortisol shown in FIGS. 1 and 2 may be secondary tostrong effects on corticosterone. To better explore this phenomenon, thelevels of corticosterone were measured in groups, which showed thestrongest changes in cortisol levels, such as groups treated withCDB-4124 at 20 mg/kg or 10 mg/kg. For comparison, the following groupswere also assayed: a group that received 20 mg/kg CDB-4124 plus 10 mg/kgprogesterone, a group that received 10 mg/kg CDB-4124 plus 10 mg/kgprogesterone, a group that received 10 mg/kg RU 486, a group thatreceived 10 mg/kg of progesterone alone, a control group. The levels ofcorticosterone were 10-40 times higher than the levels of cortisol.However, almost no difference between groups with respect to meancorticosterone levels was observed. There were no differences among thegroups before treatment (p=0.43, Kruskal-Wallis test), after 21 days oftreatment (p=0.57, Kruskal-Wallis test), or after 28 days of treatmentand at sacrifice (p=0.061, Kruskal-Wallis test.

To measure effects of exogenous progesterone on serum corticosterone,the levels of corticosterone were compared in 3 paired groups thatdiffered in whether they received exogenous progesterone (e.g.,comparisons of control versus progesterone or CDB-4124 at 20 mg/kgversus CDB-4124 at 20 mg/kg plus progesterone, or CDB-4124 at 10 mg/kgversus CDB-4124 at 10 mg/kg plus progesterone). There was astatistically significant difference detected: the levels ofcorticosterone were lowered in animals treated with progesterone after21 days of treatment (p=0.029, Mann-Whitney Wilcoxon test, two-tailed).This effect was not verified in sera taken at sacrifice. No differencesin serum corticosterone were found between the progesterone and theCDB-4124 groups, the progesterone and the RU-486 groups, or the RU-486group and the CDB-4124 groups.

The relationship between serum cortisol and serum corticosterone in eachgroup was also examined. There was a strong positive linear correlationbetween the two for CDB-4124 at 20 mg/kg (r²=0.78), for CDB-4124 at 10mg/kg (r²=0.82), and for RU 486 (r²=0.85). Adding progesterone to thefirst two CDB-4124 groups made the relationship far less strong (r²=0.34for Group 10 and r²=0.37 for Group 11, respectively). Progesteroneitself showed no such positive relationship (r²=−1.0). The control groupdemonstrated no relationship between the two glucocorticoids (r²=0.064).Thus, increased levels of cortisol in groups receiving CDB-4124 arecorrelated to levels of corticosterone, due perhaps to conversion fromcorticosterone that is somehow enhanced. This is consistent with aneffect of CDB-4124 seen above: an effect on metabolic enzymesresponsible for levels of progesterone and cortisol.

Although no strong effect of CDB-4124 on the primary glucocorticoid ofthe rat was found, nevertheless, for safety reasons, patients givenCDB-4124 or CDB-4059 in Phase I clinical trials should be monitored forpossible anti-glucocorticoid effects including a possible increase inserum cortisol, corticosterone, or ACTH.

Example 5 Testing Anti-Proliferative Effects of SPRMs in Uterine Cells

Any uterine cell lines can be used. Proliferation is measured in 96-wellmicrotiter plates. 5×10³ cells are added to each well. Culture mediumand drug solutions are added to wells with a Perkin Elmer CetusPRO/PETTE. The culture medium is IMEM supplemented with 5% fetal bovineserum. Eight drug concentrations are tested, in duplicate, from 0.078 uMto 10 uM. Samples include tamoxifen alone and each of the compoundsdisclosed in the instant specification in combination with tamoxifen.

After a four-day incubation, the medium is replaced with fresh mediumcontaining drug, and after a total of seven days, the cell monolayersare fixed with trichloracetic acid and stained with sulforhodamine dye.Absorbances (492 nm) of the extracted dye solutions are measured with aTitertek Multiscan plate reader. Dose response curves (percent ofcontrol absorbances vs. drug concentrations) are constructed in order toestimate IC₅₀ values defined as the drug concentrations (micromolar)which inhibited 50% proliferation. IC₅₀ values are correlative with apotency of a tested drug in inhibiting cell proliferation and thereforeprovide information required to identify compounds suitable forpreventing hyperproliferation of the uterine cells.

Example 6 CDB-4124 Lowers Luteal Phase Progesterone in CynomolgusMonkeys

Cynomolgus monkeys (Macaca fascicularis) (n=14) were treated orally for36 weeks with CDB-4124 or RU-486 at 1.0 mg/kg/day or with placebo(control). Another group (n=14) received Lupron® IM once per month.Urinary progesterone levels were measured for each animal for one monthduring the middle of the study (weeks 14-17) and for the last month ofthe study (weeks 33-36). The results are presented below:

Decrease in luteal phase No decrease in luteal phase progesteroneprogesterone Controls 1 13 Lupron ® 13 1 RU 486 9 5 CDB-4124 8 6

Example 7 CDB-4124 Does Not Lower Follicular Phase Estrogen inCynomolgus Monkeys

Urinary estrogen levels were measured for each animal of Example 6 forone month during the middle of the study (weeks 14-17) and for the lastmonth of the study (weeks 33-36). The follicular phase results are basedon 35 baseline ovulating cycles. The results are presented below:

Mean Sd Lower? Follicular Phase 68.3 19.6 Controls Week 18 81.5 27.4 NoWeek 36 86.3 23.8 No Lupron ® Week 18 49.9 19.3 Yes Week 36 41.7 13.4Yes RU 486 Week 18 67.4 27.1 No Week 36 64.8 30.0 No CDB-4124 Week 1863.8 24.6 No Week 36 67.3 22.9 No

Example 8 CDB-4124 and Lupron® but not RU 486 Suppress Proliferation inCynomolgus Monkey Endometrial Epithelia

At week 36, three animals from each group of Example 6 were injectedwithin 24 hours of sacrifice with the thymidine analog bromodeoxyuridine(BrdU), a marker of proliferating cells and their progeny, to assesstissue proliferation. Full thickness uterine sections were stained andexamined microscopically for evidence of proliferation in terms of the %cells positive for incorporation of BrdU:

Uterus epithelium Uterus stroma Breast TXT Brdu-% Brdu-% Brdu-% Control10.0 ± 2.5 2.6 ± 0.6 2.4 ± 1.1 Lupron ®  3.1 ± 0.8 2.2 ± 1.0 0.3 ± 0.1RU 486 12.6 ± 1.8 3.1 ± 1.0 0.9 ± 0.3 CDB-4124  2.1 ± 2.2 1.1 ± 0.25 1.9± 0.7

Example 9 CDB-4124 and RU 486 but not Lupron® Enhance Apoptosis inCynomolgus Monkey Endometrial Epithelium

Apoptosis was assessed in tissue from the same animals on slides by theterminal deoxynucleotidyl transferase mediated dUTP-biotin nick endlabeling (TUNEL) technique. The percent apoptotic cells is presentedbelow:

Uterus epithelium Uterus stroma Breast TXT Apo % Apo % Apo % Control 0.2± 0.1 0.7 ± 0.2 0.5 ± 0.3 Lupron 0.2 ± 0.1 0.2 ± 0.1 1.4 ± 0.7 RU 4860.5 ± 0.1 0.5 ± 0.1 1.2 ± 0.6 CDB-4124 0.5 ± 0.2 0.5 ± 0.1 2.6 ± 0.9

Example 10 CDB-4124 Suppresses Proliferation in Human EndometrialEpithelia in a Dose-Dependent Manner

Thirty-nine pre-menopausal adult women diagnosed with endometriosis werethe subject of a six month study of Proellex™ (CDB-4124) in thetreatment of endometriosis. The study included three dose levels ofCDB-4124 as well as a positive control arm. The positive control wasLucrin®, a GnRH agonist, commonly used for the treatment ofendometriosis (also known as Lupron®). CDB-4124 was administered in adouble blinded fashion as a daily oral capsule at dosages of 12.5 mg/day(n=2), 25 mg/day (n=3) and 50 mg/day (n=3). Another group (n=4) wereinjected with a slow release formulation of Lucrin® once per month as apositive control.

All doses of CDB-4124, as well as the Lucrin® dose, on average reduceddistress related to pain over the course of the six month exposure tothe drug, with the 50 mg CDB-4124 dose reducing both the duration andintensity of pain more effectively than the 12.5 mg or 25 mg doses andis significantly better (p=0.0012) than Lucrin® in reducing the numberof days of pain over the course of the study. Pain reduction alsooccurred more rapidly than with the active control, Lucrin®. Theresponse of pain to treatment in this study was analyzed in two ways.Patients in the study maintained daily pain diaries to record theseverity and frequency of pain. In addition, at each office visit,patients filled out endometriosis symptom surveys that included aquestionnaire that evaluated intensity of pain on a bad day on a scaleof 0-10 with 10 being the greatest intensity. Daily pain diariesindicated that on average, women on Lucrin® experienced 19.4 days ofpain over the first three months. Women on 50 mg of CDB-4124 exhibitedless than 1 day of pain over the same period. Women on 25 mg and 12.5 mgof CDB-4124 exhibited more days of pain than that recorded by womenreceiving the highest dose of CDB-4124 or Lucrin®. There appeared to bea dose dependent effect on pain reduction. Over the 180 day treatmentperiod, pain diaries indicated that women on the 50 mg CDB-4124 dose had170 or 96% pain free days (standard deviation=8.86 days). This decreasein duration of pain was statistically better (p=0.0012) than the 117.8(74%; standard deviation 51.4 days) pain free days achieved withLucrin®. The 50 mg dose of CDB-4124 was also statistically superior toboth the 25 mg and the 12.5 mg doses with regard to pain free days.Patients on CDB-4124 12.5 mg and 25 mg doses had 115.9 (66%; standarddeviation 69.2 days) and 133.6 (75%; standard deviation 27.4 days) painfree days, respectively. These results clearly support a dose responsefor CDB-4124. The 25 mg and 12.5 mg doses of CDB-4124 were notstatistically different from Lucrine®. At the end of the first month oftherapy there was a statistically significant reduction in days of painin the 50 mg Proellex group (p=0.031) compared with baseline, but not inthe three other treatment groups. The intensity of pain was asked by thequestion: “On a scale of 1-10, with 0 being no pain and 10 being extremepain, how intense was your pain on a bad day?” The mean scores forintensity of pain at baseline were 6.3 for the CDB-4124 groups and 6.1for the Lucrin® group. Statistically significant relief from pain wasevident by the first month in the 25 mg and 50 mg Proellex groups. Atmonth three all four active treatment groups had statisticallysignificant reduction in pain compared with baseline, with the followingscores: 3.7 (p=0.03) for 12.5 mg CDB-4124, 3.2 (p=0.03) for 25 mgCDB-4124, 1.6 (p=0.015) for 50 mg CDB-4124 and 1.5 (p=0.016) forLucrin®. These dose related reductions continued until month six whenthe values for pain intensity were 2.0 (p=0.008), 2.8 (p=0.023), 0.6(p=0.004) and 0.7 (p=0.016), respectively. Two months after stoppingtreatment pain returned and was of similar intensity in all fourtreatment groups.

Women receiving Lucrin® in the study, on average, experienced areduction of estrogen to post-menopausal levels (<20 pg/ml) by monththree and this was maintained through month six of treatment. Thisoutcome was associated with a statistically significant increase(p=0.023) in biomarkers of bone resorption compared with the baselinevalues at month three, and therefore an increased risk of bone loss. Atmonth six as well as at the one-month follow up visit, this increase inmarkers of bone resporption was still present in women treated withLucrin®. All doses of CDB-4124 maintained estrogen concentrationssignificantly above those seen with Lucrin® and remained in the lownormal range (mean>40 pg/ml). Importantly, there were no significantchanges in biomarkers of bone resorption in any of the dose aims ofCDB-4124 at three and six months of treatment. Women withpost-menopausal levels of estrogen have been shown to be at greater riskfor bone loss and other medical conditions. Lucrin®, therefore, is notindicated for treatment lasting longer than six months.

Side effects of CDB-4124 were generally mild with no individual organsystem being involved systematically. Although this was a small studyand no definitive conclusions can be made from the safety data, therewas no single signal of safety observed.

Women in the study were closely monitored for changes in the structureof the endometrium. Data from these examinations suggest an inverse dosedependent effect of CDB-4124 on endometrial thickness at the three monthperiod. Comparisons were made to both baseline and visit one ultrasoundmeasurements of endometrial thickness. After three months on treatmentnone of the women receiving the 50 mg dose of CDB-4124 (n=3) exhibitedthickened endometrium and actually exhibited a trend toward reduction inendometrial thickness compared to baseline. One woman receiving the 25mg dose of CDB-4124 (n=4) and two women receiving the 12.5 mg dose ofCDB-4124 (n=4) exhibited a thickened endometrium. The five women whoreceived Lucrin® did not have a thickening of the endometrium due to alow estrogenic state. The results are presented below:

Endometrium (mm) screening 1^(st) dose 3 months Lupron 7.9 7.5 2.75CDB-4124 (12.5 mg) 7.5 8.0 20.33 CDB-4124 (25 mg) 8.4 11.7 19.6 CDB-4124(50 mg) 8.0 10.8 7.7

In two cases where non-menstrual spotting and bleeding was observed inpatients with excessive endometrial thickening in the 12.5 mg and 25 mgCDB-4124 groups, a dilation and curettage (D&C) procedure was performedto stop the bleeding. A similar event was not seen at the 50 mg doseduring the treatment phase. Greater than normal bleeding occurred in twopatients in the 50 mg CDB-4124 group after treatment was stopped and aD&C was performed in one and the other successfully managedconservatively.

We claim:
 1. A method for treating chronic estrogen-dependenthyperproliferation of uterine tissue according to an intermittentadministration regimen comprising administering to a human female inneed of such treatment a therapeutically effective amount of a selectiveprogesterone receptor modulator (SPRM) for an administration periodduring which the SPRM is administered daily or every other dayconsecutively over a period of from one to six months, thendiscontinuing said administration for a discontinuance period by meansof a continual lack of treatment for a period of time sufficient for thefemale to undergo menstruation, said period of time being equal to orless than the number of days during which the SPRM was previouslyadministered, then administering a therapeutically effective amount ofan SPRM daily or every other day consecutively over a period of from oneto six months, then discontinuing said administration by means ofcontinual lack of treatment for a period of time sufficient for thefemale to undergo menstruation, said period of time being equal to orless than the number of days during which the compound was previouslyadministered, and repeating this pattern of administration anddiscontinuance of administration for a sufficient duration to treat thechronic condition.
 2. The method of claim 1, wherein the effectiveamount of SPRM is from 2 mg to 80 mg.
 3. The method of claim 1, whereinthe SPRM is administered daily during the administration period.
 4. Themethod of claim 1, wherein the administration period is about threemonths.
 5. The method of claim 4, wherein the administration period isabout four months.
 6. The method of claim 1, wherein the female isadministered a progestin in an amount effective to induce menstruationduring the discontinuance period.
 7. The method of claim 6, wherein thefemale is administered a progestin selected from the group consisting ofmedroxyprogesterone, hydroxyprogesterone and progesterone.
 8. The methodof claim 1, wherein the SPRM is a compound of formula (I):

or a pharmaceutically acceptable salt, hydrate or solvate thereof,wherein: X represents an alkyl, alkenyl, alkynyl, hydrogen, halo,monoalkylamino or dialkylamino; R₁ represents ═O, ═NOH or ═NO-methyl; R₂represents a hydrogen or acetyl; and R₃ represents methyloxy, formyloxy,acetoxy, acyloxy, S-alkoxy, acetyltheonyl, glycimate, vinyl ether,acethyloxymethyl, methyl carbonate, halogens, methyl, hydroxy, orethyloxy.
 9. The method of claim 8, wherein said compound is CDB-4124(21-methoxy-17α-acetoxy-11β-(4-N,N-dimethylaminophenyl)-19-norpregna-4,9-diene-3,20-dione).10. The method of claim 9, wherein the administration period is aboutfour months.
 11. The method of claim 10, wherein the compound isadministered daily.
 12. The method of claim 1, wherein the SPRM is17α-acetoxy-11β-(4-N,N-dimethylaminophenyl)-19-norpregna-4,9-dien-3,20-dione.13. The method of claim 12, wherein the administration period is aboutthree months.
 14. The method of claim 13, wherein the SPRM isadministered daily.
 15. The method of claim 1, wherein thediscontinuation period is at least 32 days.